Center for Clinical and Translational Research
Radiology Clinical Research Imaging Core
Radiology Research Imaging Study Set Up Form
Date:
A. STUDY TEAM INFORMATION
Principal Investigator:
Phone:
Email:
Mailstop:
Position:
Faculty
Staff
Post-doc/Fellow
Department/Division:
SCRI Research Center:
Primary Research Staff Contact (if not PI):
Phone :
Email:
Pager:
Approximate dates for radiology services (or project term):
to
(Month/Year)
B. PROJECT INFORMATION
Full Project Title:
IRB Application Number:
(Please specify if submitted, not submitted or give approval date)
RS_ Study Code, if known:
Lawson Activity:
Sponsor:
Type of Funding:
Public
Private, non-profit
Other:
Corporate
Unfunded (sponsorship pending)
(e.g. ITHS, Department)
Project Summary related to imaging work:
C. Want Radiology Consulting (research design, protocol development, etc):
D. Want Clinical Research Associate Dedicated time:
Yes
No
E. Want Image/exam anonymizing, downloading and copying: Yes
No
Yes
No
Center for Clinical and Translational Research
Radiology Clinical Research Imaging Core
F. REQUESTED IMAGING SERVICES (Check all that
SPECIFIC CLICNIAL EXAM eg. CT Abdomen, DX Chest 2V,
apply)
MRI Cardiac w/o (Please include description if not known)
Computed Tomography (CT)
DEXA
Fluoroscopy
Magnetic Resonance Imaging (MRI)
Nuclear Medicine
Positron Emission Tomography (PET)
Plain radiographic images (DX)
Ultrasound (US)
Other (e.g. interventional procedures)
G. STUDY DETAILS FOR RADIOLOGY IMAGING
# subjects to receive imaging
# imaging scans per subject
Age range of subjects
Population (check all that apply)
Inpatient
Outpatient
Anesthesia/sedation
YES
Is a specific radiologist involved?
YES; Name:
Purely study patient
NO
NO
Best contact for imaging questions
Subject gender
All females
All males
Both females and males
Please complete and email this form along with the protocol related to the imaging scans to
RadiologyResearch@seattlechildrens.org. Contact Pat Smoll via email or at 987-2249 if you have any questions.
RCRIC Review Date:
Review Result: